Therapy is my J.A.M., LLC | SimplePractice

Therapy is my J.A.M., LLC Send Message

Who would be receiving care?

My partner and me

Your info

First name

Last name

Phone

Date of birth

Gender

State

Select the state you live in

Reason for care

What is the reason for seeking my services at this time?

Limited to 600 characters

What are you hoping to gain from our work together?

Limited to 600 characters

Are you currently struggling with any of the issues below?

Drug use Alcohol use Legal Action None of these apply

Do you currently have any thoughts or desire to harm yourself or someone else?

Yes No

Do you have any history of suicide attempts or suicidal ideation in the past?

Yes No

Administrative

Which services are you interested in?

I am only credentialed with Carefirst/BCBS and Cigna insurance and insurance is only accepted for individual sessions.

How did you hear about my services?

Google, Therapy for Black Girls, Word of Mouth, etc.

Billing & Payment

Payment method

How do you plan to pay?

Insurance details

Type of Insurance + Member ID

Client Preferences

Preferred appointment times

What times would be best for regular appointments?

Lunch Time (11 a.m. - 1 p.m.) Early Afternoon (1 p.m. - 3 p.m.) Late Afternoon (3 p.m. - 5 p.m.) Evening (5 p.m. - 7 p.m.)

Preferred Day of the Week

What days would be best for regular appointments?

Monday Tuesday Wednesday Thursday

Is there anything else that you would like me to know or further questions?

For example: what you'd like to focus on, insurance or payment questions, etc.

Limited to 600 characters

Would you like to be added to my newsletter?

Yes, I'd love that. No thanks, just need therapy

Would you like a 15 minute intro call?

Sure, I'd like to speak with you before I book a session. No, I'm ready to schedule my first session

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.